Fortunately for the Medicare budget, but unfortunately for patients, so few people understand this portion of their Medicare coverage that they often fail to access these benefits. Federal Medicare guidelines call for skilled care, which includes nursing, physical, occupational, and speech therapy, home health aides, and social services, so long as your ability to leave the house is restricted to infrequent, supervised excursions either with an attendant or with a cane or walker.
However, you can’t expect Medicare Home Health Benefit to provide around-the-clock skilled care. The benefit available is limited and is intended to cover only skilled nursing care and home health aide services on a part-time or intermittent basis.
The statute states that the term “part-time or intermittent services” pertains to combined services that total less than eight hours per day. In special circumstances with physician documentation these limits can be increased up to less than eight hours each day.
The statute further defines “intermittent” as skilled nursing care or home health aide services that are needed or given on fewer than seven days each week or less than eight hours each day over a period of 21 days (or less). There is no sunset to these services; as long as the need is documented, and you have the willpower and resources to claim the care. Nor is there a deductible or co-payment for these services, although this is another area where you should stay tuned for developments.
Only a few state legislatures fund advocacy projects for citizens who have trouble with their Medicare coverage. The managing attorney for the Medicare Advocacy Project at Greater Boston Legal Services in Massachusetts, Diane Paulson, told me that even patients who know about the home care benefits may find them difficult to access.
Paulson says that qualifying for the coverage is “very hard.” It may also be difficult to find certified agencies to provide skilled services, especially since the Medicare reimbursement for patients who demand considerable care is often considered inadequate by the agency. She adds that since Medicare only pays for care once it’s administered and does not give prior approval, the patient may be financially liable for the care if the federal program does not pay the bill. According to Paulson, “Many people can’t afford that assumed financial risk,” and since the only way to “challenge” Medicare is to submit a bill, they forgo the service.
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